[Hip impingement surgery: reimbursement in the German DRG system]. / Impingement-Chirurgie: aufwändige Therapie, unterbewertetes Verfahren?

The financial benefit that orthopaedic surgery provides affects the profitableness for both hospitals and centres for outpatient care. Due to on-going evaluation, surgical techniques have been improved over time. Thus, standardized interventions have resulted in a reduction of remuneration for institutions caring for both outpatients and inpatients, no matter whether private or state insurance was applied. This article depicts current payments for arthroscopic hip intervention. It is also an issue of which surgeons caring for inpatients and outpatients should be aware. The following coding should not be regarded as a recommendation, but simply as a guide.

[Surgical treatment of femoroacetabular impingement syndrome : Arthroscopy-mini-open-surgical hip dislocation]. / Auswahl des Operationsverfahrens beim Femoroazetabulären Impingement-Syndrom : Arthroskopie ­ "mini-open" ­ chirurgische Hüftluxation.

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) is one of the most common prearthritic hip deformities. Since FAIS is a mechanical pathology, surgical correction of the underlying deformity is the sole causal treatment. If surgery is indicated, a surgical technique that results in complete deformity correction with least morbidity should be selected. ARTHROSCOPY: Due to advancements in techniques and instruments, most pathologies in FAIS can nowadays be addressed arthroscopically. Hip arthroscopy can be successfully performed if the locations of the pathologies are anterior and lateral. MINI-OPEN APPROACH: In special cases and indications-like periarticular pathologies, pathologies of the hip capsule and large labral reconstructions and transplantations, a combination of arthroscopy with a mini-open approach is advantageous. Furthermore, the learning curve of hip arthroscopy can be improved with an additional open approach. SURGICAL HIP DISLOCATION: Global and circumferential pathologies still have to be addressed in surgical hip dislocation to avoid residual deformities. Finally, extraarticular osteotomies have to be considered in cases with significant rotational deformities.

[Biologic Reconstruction of Full Sized Cartilage Defects of the Hip: A Guideline from the DGOU Group "Clinical Tissue Regeneration" and the Hip Committee of the AGA]. / Biologische Rekonstruktion lokalisiert vollschichtiger Knorpelschäden des Hüftgelenks: Empfehlungen der Arbeitsgemeinschaft "Klinische Geweberegeneration" der DGOU und des Hüftkomitees der AGA.

Background Symptomatic pre-arthritic deformities such as femoroacetabular impingement (FAI) or hip dysplasia often lead to localised cartilage defects and subsequently to osteoarthritis. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) and the hip committee of the AGA (German speaking Society for Arthroscopy and Joint Surgery) provides an overview of current knowledge of the diagnosis and surgical treatment of cartilage defects, in order to infer appropriate therapy recommendations for the hip. Methods Review of FAI and resultant cartilage damage in the hip as reported in published study findings in the literature and discussion of the advantages and disadvantages of different surgical procedures to preserve the joint. Results Most published studies on the surgical treatment of cartilage damage in the hip report defects caused by cam-type FAI at the acetabulum. Development of these defects can be prevented by timely elimination of the relevant deformities. At present, current full-thickness cartilage defects are mostly treated with bone marrow-stimulating techniques such as microfracture (MFx), with or without a biomaterial, and matrix-assisted autologous chondrocyte transplantation (MACT). Osteochondral autologous transplantation (OAT) is not the treatment of choice for isolated full-thickness chondral defects at the hip, because of the unfavourable risk-benefit profile. Due to the relatively short history of cartilage repair surgery on the hip, the studies available on these procedures have low levels of evidence. However, it is already becoming obvious that the experience gained with the same procedures on the knee can be applied to the hip as well. For example, limited healing and regeneration of chondral defects after MFx can also be observed at the hip joint. Conclusions The cartilage surface of the acetabulum, where FAI-related chondral lesions appear, is considerably smaller than the weight-bearing cartilage surface of the knee joint. However, as in the knee joint, MACT is the therapy of choice for full-thickness cartilage defects of more than 1.5 - 2 cm2. Minimally invasive types of MACT (e.g. injectable chondrocyte implants) should be preferred in the hip joint. In cases where a single-stage procedure is indicated or there are other compelling reasons for not performing a MACT, a bone marrow-stimulating technique in combination with a biomaterial covering is preferable to standard MFx. For treatment of lesions smaller than 1.5 - 2 cm2 the indication for a single-stage procedure is wider. As with defects in the knee, it is not possible to determine a definite upper age limit for joint-preserving surgery or MACT in the hip, as the chronological age of patients does not necessarily correlate with their biological age or the condition of their joints. Advanced osteoarthritis of the hip is a contraindication for any kind of hip-preserving surgery. Long-term observations and prospective randomised studies like those carried out for other joints are necessary.

Tumoral calcinosis revisited: pathophysiology and treatment.

In two renal failure patients, tumoral calcinoses were observed as a result of secondary hyperparathyroidism. The primary conservative therapy conducted with dietetic measures and phosphate-binding medication could not prevent the progression of the massive polytopic foci. Therefore, a subtotal parathyroidectomy was performed in one case, after which a rapid complete regression of the tumours was observed, with the exception of one location where the finding remained progressive. The second patient declined surgical intervention on the parathyroid gland. Therefore, the foci were only resected, whereby local recurrences were observed. Renal failure patients with tumoral calcinosis should undergo subtotal parathyroidectomy after initial conservative therapy. In view of the high risk of recurrence, local excision is a treatment procedure to be considered in exceptional cases only.

The influence of walking speed on kinetic and kinematic parameters in patients with osteoarthritis of the hip using a force-instrumented treadmill and standardised gait speeds.

BACKGROUND: It is difficult to identify objective parameters for assessing the joint function when dealing with the evaluation of orthopaedic procedures, especially endoprosthetic hip replacement. Clinical gait analysis enables parameters of force and movement to be quantified. However, the influence of gait speed on these parameters has hardly been taken into consideration so far. The objective of the present study was therefore to investigate the effect of gait speed on gait parameters and to simplify the clinical conditions in patients with osteoarthritis of the hip by determining a standardised gait speed. METHODS: A total of 28 patients with severe unilateral osteoarthritis of the hip were investigated at different gait speeds. The gait analysis equipment used consisted of an infinitely adjustable treadmill with force plates and an infrared video system. A special control mechanism permitted adjustment of the treadmill speed to a patient's self-determined pace. RESULTS: The mean gait speed of all patients with osteoarthritis of the hip was set at 2.20 km/h (0.61 m/s). Eight of the 10 gait parameters assessed increased significantly with changing gait speed. Pathological changes in gait patterns were found at the three gait speeds investigated, with the changes more accentuated at higher speeds. CONCLUSIONS: Dependence of gait parameters on gait speed could be concluded for a group of patients and for control subjects. Use of a force-instrumented treadmill is necessary for the setting of a standard gait speed, which should be set as high as achievable by patients without inducing pain and problems of coordination or balance. With the usage of standardised speeds, clinical gait analysis becomes easier to perform. Furthermore, one can assess the expected biomechanical advantages of newer prostheses, thus providing the surgeon with a basis for further decisions.